OMB: 1110-0066
FD-1116 (2-25-2015)
REQUEST FOR EMERGENCY OR TERM ACCESS TO NATIONAL SECURITY INFORMATION
You are being considered for emergency or limited term access to National Security Information. Prior to receiving that information, you
are required to sign a Non-Disclosure Agreement. Eligibility for access to classified information may be granted when there is an urgent
need, provided that an imminent threat to national security exists and such access is commensurate with the standards established in
Executive Order 13549. In such cases, a fixed date for expiration shall be identified and access to classified information shall be limited to
information related to the particular event or threat. This access is not to be considered a security clearance.
PERSONAL INFORMATION
Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you do not have a middle
name, indicate “No Middle Name”. If you are a “Jr.”, “Sr.”, etc. enter this under Suffix.
Last Name
First Name
Middle Name
Suffix
Have you used any other names?
YES
NO If “YES”, use the space available below to provide your other name(s) used and the
period of time you used it/them [for example your maiden name(s), name(s) by a form marriage, former name(s), alias(es), or
nickname(s)].
Date of Birth (MM/DD/YYYY) Place of Birth: City
County
State Zip Code Country
EST
Social Security Number
Email Address
U.S. Citizen?
YES
Dual Citizen Country
NO
OTHER NAMES USED
(1) Last Name
First Name
From (MM/YYYY)
To (MM/YYYY)
EST
(2) Last Name
From (MM/YYYY)
To (MM/YYYY)
EST
(3) Last Name
From (MM/YYYY)
To (MM/YYYY)
EST
(4) Last Name
From (MM/YYYY)
To (MM/YYYY)
EST
Middle Name
PRESENT
EST
First Name
Maiden Name?
YES
NO
PRESENT
EST
First Name
Maiden Name?
YES
NO
PRESENT
EST
First Name
Maiden Name?
YES
NO
PRESENT
EST
Maiden Name?
YES
NO
Suffix
Provide the reason(s) why name changed?
Middle Name
Suffix
Provide the reason(s) why name changed?
Middle Name
Suffix
Provide the reason(s) why name changed?
Middle Name
Suffix
Provide the reason(s) why name changed?
This is a legally binding document between you and the Federal Bureau of Investigation (FBI). It outlines your three lifetime obligations that
occur as a result of receiving access to classified information. (For individuals with prior clearances – you have already agreed to abide by
these obligations when you were initially indoctrinated and then debriefed.)
Lifetime Obligations:
Safeguarding Protected Information: This means that you are required to protect all classified and unclassified information to which you
have access. There are three levels of classification:
•
•
•
1
Top Secret - compromise can cause exceptionally grave damage to national security
Secret – compromise can cause serious damage to national security
Confidential – compromise can cause damage to national security
Enter your SSN before going to the next page.
OMB: 1110-0000
FD-1116 (2-25-2015)
REQUEST FOR EMERGENCY OR TERM ACCESS TO NATIONAL SECURITY INFORMATION
Divulging classified information may be considered espionage and is prosecuted under Title 18 of the United States Code, under sections
793, 794, and 798.
•
•
•
793 prohibits the gathering, transmitting or loss of defense information
798 prohibits the unauthorized disclosure of codes, ciphers, etc. of the U.S. government or a foreign government (e.g. our 2nd
party partners). The penalties for 793 & 798 are $10,000 per offense and heavy fines.
794 prohibits the gathering and delivering of defense information to a foreign government. The penalty for 794 is life in jail or the
death penalty.
Prepublication Review: If you plan to discuss or publish anything related to what you learn as a result of your briefing or your affiliation
with the FBI, the content must be reviewed by the FBI. You must contact the FBI’s Records Management Division, Record/Information
Dissemination Section, 540-868-4500 or 202-324-3000. This includes publication in a resume, articles, internet postings, books, etc.
Reporting Unauthorized Disclosures: If you divulge classified information to an unauthorized person or if you become aware of someone
else divulging classified information, you must report it immediately. Also, if someone tries to solicit protected information from you,
report it immediately. Contact: FBI Security Division, Security Program Unit, 202-651-2245, or your local FBI field office’s Chief Security
Officer.
Privacy Act Statement
The FBI is authorized to collect the information on this form pursuant to one or more of the following authorities Executive Order 12968 (as
amended), Access to Classified Information (August 2, 1995), Executive Order 13467, Reforming Processes Related to Suitability for Government
Employment, Fitness for Contractor Employees, and Eligibility for Access to Classified Information (June 30, 2008), Executive Order 13526,
Classified National Security Information (December 29, 2009), Executive Order 13549, Classified Information Programs for State, Local, Tribal
and Private Sector Entities (Aug 18, 2010), Executive Order 13587, Structural Reforms to Improve the Security of Classified Networks and the
Responsible Sharing and Safeguarding of Classified Information (October 7, 2011), and Executive Order 13636, Improving Critical Infrastructure
Cybersecurity (February 12, 2013). The FBI is authorized to collect your Social Security Number pursuant to Executive Order 9397 (November
30, 1943), as amended by Executive Order 13478 (November 18, 2008). The information provided will be used by the FBI to conduct a
background investigation to determine your eligibility for emergency access to National Security information. Your disclosure of the requested
information is voluntary. However, failure to provide all of the requested information will prevent completion of your background investigation
and will adversely affect your eligibility for emergency access to National Security information. The information provided will be maintained in
the FBI Central Records System (CRS), Justice/FBI-002, notice of which was published in the Federal Register on February 20, 1998 (63 FR 8671).
The information provided may be disclosed in accordance with the routine uses identified in that notice or as otherwise authorized by law.
Certification
By my signature below, I authorize the FBI to conduct a background investigation to determine my eligibility for access to National
Security information.
Signature (Sign in Ink)
2
Date Signed (MM/DD/YYYY)
Enter your SSN before going to the next page.